BMC Complementary and Alternative Medicine 2006, 6:19

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1 BMC Complementary and Alternative Medicine This Provisional PDF corresponds to the article as it appeared upon acceptance. The fully-formatted PDF version will become available shortly after the date of publication, from the URL listed below. Use of complementary and alternative medicine in Germany - a survey of patients with inflammatory bowel disease BMC Complementary and Alternative Medicine 2006, 6:19 doi: / Stefanie S Joos (stefanie.joos@med.uni-heidelberg.de) Thomas T Rosemann (thomas.rosemann@med.uni-heidelberg.de) Joachim J Szecsenyi (joachim.szecsenyi@med.uni-heidelberg.de) Eckhart E Hahn (Eckhart.Hahn@med1.imed.uni-erlangen.de) Stefan S Willich (stefan.willich@charite.de) Benno B Brinkhaus (benno.brinkhaus@charite.de) ISSN Article type Research article Submission date 23 November 2005 Acceptance date 22 May 2006 Publication date 22 May 2006 Article URL Like all articles in BMC journals, this peer-reviewed article was published immediately upon acceptance. It can be downloaded, printed and distributed freely for any purposes (see copyright notice below). Articles in BMC journals are listed in PubMed and archived at PubMed Central. For information about publishing your research in BMC journals or any BioMed Central journal, go to Joos et al., liceee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commo Attribution Licee ( which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Use of complementary and alternative medicine in Germany a survey of patients with inflammatory bowel disease Stefanie Joos 1,2, Thomas Rosemann 1, Joachim Szecsenyi 1, Eckhart G Hahn 2, Stefan N Willich 3, Benno Brinkhaus 2,3 1 Department of General Practice and Health Services Research, University of Heidelberg, Germany 2 Department of Medicine I, Friedrich Alexander University of Erlangen Nuremberg, Erlangen, Germany 3 Ititute of Social Medicine, Epidemiology, and Health Economics, Charité University Medical Center, Berlin, Germany Corresponding address: Dr. Stefanie Joos, MD Department of General Practice and Health Services Research University of Heidelberg Voßstrasse 2 D Heidelberg stefanie.joos@med.uni-heidelberg.de Phone: +49 (0) Fax: +49 (0)

3 Abstract Background: Previous studies have suggested an increasing use of complementary and alternative medicine (CAM) in patients with inflammatory bowel disease (IBD). The aim of our study was to evaluate the use of CAM in German patients with IBD. Methods: A questionnaire was offered to IBD patients participating in patient workshops which were organized by a self-help association, the German Crohn s and Colitis Association. The self-administered questionnaire included demographic and disease-related data as well as items analysing the extent of CAM use and satisfaction with CAM treatment. Seven commonly used CAM methods were predetermined on the questionnaire. Results: 413 questionnaires were completed and included in the analysis (n=153 male, n=260 female; n=246 Crohn s disease, n=164 ulcerative colitis). 52 % of the patients reported CAM use in the present or past. In detail, homeopathy (55%), probiotics (43%), classical naturopathy (38%), Boswellia serrata extracts (36%) and acupuncture/traditional Chinese Medicine (TCM) (33%) were the most frequently used CAM methods. Patients using probiotics, acupuncture and Boswellia serrata extracts (incee) reported more positive therapeutic effects than others. Within the statistical analysis no significant predictors for CAM use were found. 77% of the patients felt iufficiently informed about CAM. Conclusio: The use of CAM in IBD patients is very common in Germany, although a large proportion of patients felt that information about CAM is not sufficient. Therefore, physicia should increasingly inform IBD patients about benefits and limitatio of CAM treatment. However, more research in this field is desperately needed to provide an evidence-based approach. CAM in IBD patients 2

4 CAM in IBD patients 3

5 Background The use of complementary and alternative medicine (CAM) is widespread and still increasing in the Western world [1;2]. The term complementary medicine refers to a group of diagnostic and therapeutic disciplines that exist largely outside the ititutio where conventional health care is provided and taught [3]. The wide range of disciplines classified as complementary medicine makes it difficult to find defining criteria that are common to all. Furthermore, the diagnostic and therapeutic approaches which are summarized among the term CAM depend on traditio and historical developments of a country and therefore, vary coiderably among countries [4]. Also, the extent to which CAM is practiced by physicia or nonmedical therapists differs coiderably among countries. In Germany, medical doctors can obtain a variety of additional qualificatio relating to specific CAM methods (e.g. chiropractic, homeopathy) or to naturopathic medicine in general (naturopathy). In 2004 the German federal medical chamber documented additional qualificatio of medical doctors in chiropractic, in homeopathy and in naturopathy (= 18.5% physicia working in the ambulatory sector). In addition, about 2.5% of the ambulatory physicia are qualified in the field of physical medicine [5]. Furthermore, around 25% of the physicia in the ambulatory sector have passed a special training in acupuncture. In near future, acupuncture will also be a qualification accredited by the local medical chambers such as chiropractic or homeopathy. Moreover, in Germany many physicia are providing CAM in their daily practice without having an additional CAM qualification [6]. Other health care professionals such as pharmacists, dentists, physiotherapists or midwives also practise some form of CAM. Official data on CAM qualificatio for these health care professio are not available. CAM in IBD patients 4

6 Apart from the regular health care professionals Germany has one state-regulated profession the Heilpraktiker. A Heilpraktiker has to pass an examination on basic medical knowledge and skills at a local public health office to obtain a state licee. Heilpraktiker only practice in the ambulatory sector and their services are not covered by health iurance funds. Any CAM method can be performed by a Heilpraktiker as long as it is coistent with the general standards of good professional practice in health care as supervised by the local public health office. In general Heilpraktiker provide a variety of CAM methods. Within the last ten years the number of Heilpraktiker increased from in the year 1993 to nearly today. In Germany, the overall percentage of individuals with CAM experience increased from 52% in 1970 to 73% in 2002 [5]. A recently published national representative sample shows that herbal medicine, exercise therapy and hydrotherapy are the most frequently used CAM methods [7] - all of them belonging to the so-called classic naturopathy, also known as kneippism from its originator Sebastian Kneipp ( ), a German priest. Besides the classic naturopathic methods homeopathy, manual therapy and acupuncture are commonly used CAM therapies in Germany [7]. It is commonly known, that patients with chronic diseases rank high among CAM users. Several surveys in patients with IBD have shown rates of CAM utilization ranging from 39% in Austria to 47% in Switzerland and Canada [8-11]. A survey among German IBD patients found 51% with experience in CAM. Homeopathy and herbal medicine were the most commonly used types of CAM in this recently published survey [12]. The purpose of our study was to estimate the extent of CAM experience among IBD patients in Germany and to obtain information about the most commonly used CAM methods, about CAM providers and about perceived effects of CAM therapy. CAM in IBD patients 5

7 Methods Participants and Data Collection We surveyed IBD patients meeting at patient workshops organized by the German Crohn's and Ulcerative Colitis Association (DCCV e.v.). The DCCV [13] is a national organization established by patients and for patients with Crohn s disease (CD) and Ulcerative Colitis (UC). The patient workshops of the DCCV take place regularly in different regio of Germany and are open to the public. Normally experts are invited to give lectures on recent developments in diagnostic and therapeutic possibilities in order to inform patients. Three of these workshops (which were not specific to CAM) took place in different German federal states (Erlangen; October 1998/ Aachen; May 2000/ Tübingen; June 2000). A questionnaire was handed out to all participants of the workshops. The questionnaires were distributed on the tables in the convention hall and had to be completed during the workshop or were to be returned by mail. Questionnaire The 4-page structured self-administered questionnaire contained questio on patients demographic data (10 items) and on characteristics of the disease such as duration of disease, current medication and satisfaction with conventional therapy (16 items). Detailed questio were asked about knowledge and interest in CAM and CAM use specifically for their IBD symptoms (15 items). The items were designed as yes/no questio or open-ended questio or to be awered on a 5-point Likert scale. Within the questionnaire CAM was defined as all non-conventional therapy methods, which are based rather on personal experience than on a scientific basis. Seven CAM therapies which are commonly used in Germany were predetermined in the questionnaire: classic naturopathic medicine (incl. herbal medicine and CAM in IBD patients 6

8 hydrotherapy), Traditional Chinese Medicine incl. acupuncture (TCM), homeopathy, Boswellia serrata (incee), probiotics, neural therapy (= pain therapy with local anaesthetics) and anthroposophic medicine. Patients were asked to assess the perceived therapeutic effect of CAM treatment on a 5-point Likert scale and to indicate where they received the CAM therapy: general practitioner, gastroenterologist, clinician or Heilpraktiker (=state registered nonphysician CAM practitioner). Data analysis Data analysis was completed with SPSS (Version 9.0). Descriptive statistics (mean and proportio) were used to describe each variable. The chi-square test was used to identify significant differences in CAM use regarding possible predictive patient characteristics such as age, gender, weight, graduation level, membership of DCCV, site of workshop, disease, current medication, smoking status, special diets, regular exercise or type of health iurance. Since no significant differences were found for any of these variables during statistical analysis, data in the result section will be presented for the complete sample only. Due to the fact that probiotic therapy was missing on the list of predetermined CAM methods within the Erlangen questionnaire, the percent values for probiotic use were calculated for the sample without Erlangen patients. CAM in IBD patients 7

9 Results Respondents According to information given by the German Crohn's and Ulcerative Colitis Association about 250 patients participated at the workshop in Aachen, 250 patients in Tübingen and about 340 patients in Erlangen (n total = 840). Altogether 413 patients completed and returned the questionnaire which corresponds to an overall respoe rate of 49% (Erlangen 61%, Aachen 35%, and Tübingen 47%). All 413 questionnaires were included in the final analysis sample. All in all there was a greater proportion of patients with Crohn s disease (n=246) than with Ulcerative Colitis (n=164) returning the questionnaire. 3 patients did not indicate their diagnosis. Table 1 shows the demographic, disease-related and treatment characteristics. Duration of disease was 14 ys in average and patients coulted their general practitioner about 12 times a year for their IBD. About 80% of the patients had been hospitalised because of IBD at least once and 39% had undergone some kind of surgical intervention for their IBD. 45% of the patients stated that they were satisfied with their current conventional treatment: 64% of the patients receiving aminosalycilates, 36% being treated with corticosteroids and 17% taking immunosuppressive drugs (Table 1). 55% of the IBD patients reported side-effects due to their conventional treatment. 25% of the patients were on a special diet (vegetable diet, sugar-reduced diet, whole foods etc.). On a 5 -point Likert scale 32 % of the patients indicated that they feel stressed or highly stressed by their disease on a physical level and 36% on a mental level. Comparing the three sites Erlangen (n = 207), Aachen (n = 88) and Tübingen (n = 118) some small, however not significant differences were found. Tübingen-patients had been slightly less hospitalised and had undergone fewer surgical interventio compared to patients in Erlangen and Aachen. In addition, the application of CAM in IBD patients 8

10 pharmacotherapy, in particular aminosalicylates, was slightly lower among Tübingenpatients. Use and provider of CAM 52% (n=215) of all patients reported the use of some form of CAM to treat their IBD currently or in the past (Table 2). The most frequently used therapy method was homeopathy (55%), followed by probiotics (43%), classical naturopathy (38%), Boswellia-serrata extracts (36%) and acupuncture/tcm (33%). Anthroposophic medicine (7%) and neural therapy (5%) were applied less frequently. CAM was initiated in 40% by a general practitioner, in 29% by a practicing gastroenterologist and in 15% by a clinician. 44% of the patients visited a so-called Heilpraktiker for the CAM treatment. 54% of those patients, who received CAM treatment not by their general practitioners, informed their GP about the additional treatment with CAM. There were no significant differences in CAM use regarding any patient-related characteristics. Benefit, risks and costs of CAM Within the questionnaire patients were asked on a 5-point Likert scale how satisfied they were regarding CAM treatment for IBD. Most satisfied were patients treated with probiotics (57%), followed by patients treated with acupuncture/tcm (49%) and Boswellia serrata extract (44%) (Table 3). 15% of the CAM users notified side effects of the CAM treatment, in general. However, the questionnaire did not assess side effects of specific CAM methods in detail. 73% of the patients receiving CAM reported that they financed the treatment in part or completely themselves. Only 23% of all patients felt sufficiently informed about CAM treatment in IBD. Most respondents required that CAM should be reimbursed CAM in IBD patients 9

11 by the statutory health iurance (96%) and that research in CAM should be increased (97%). Discussion 52% of the 413 patients participating in our survey reported some form of current or previous CAM use for their IBD. These findings correspond to results in previous surveys in selected groups of IBD patients attending specialty clinics in North America and European countries [8;10;11;14]. In our survey homeopathy was the most frequently used CAM method, followed by probiotics, classical naturopathy (including herbal therapy), Boswellia serrata extracts and acupuncture/tcm. However, it is difficult to compare surveys of CAM utilization among countries because the exteion of specific CAM methods is tightly linked to the traditional and cultural background of a country. While herbal products are very popular both in North America and in Europe, homeopathy is less used in North America, but very popular in Europe. As expected, the most commonly used CAM methods among our IBD patients are comparable with data from the neighbouring countries Austria and Switzerland [9;10]. In both of these countries as well as in the German survey of Langhorst et al. homeopathy was the most frequently used CAM method [12]. Various previous surveys have indicated that CAM users are generally more likely to be female and to be better educated [7;15]. In our study, duration of disease, gender, age and previous surgery /hospitalisation were not predictive for the use of CAM. Nor we could confirm the findings of Langhorst et al that steroid medication and academic education are strong predictors for CAM use [12]. Furthermore our results do not support the assumption that our patients use CAM because of dissatisfaction with conventional treatment or side effect profile of conventional medication. This lack of CAM-predictors is in accordance with the Swiss survey of Quattropani et al [10]. CAM in IBD patients 10

12 Accordingly, due to our data IBD patients using CAM seem not so different from nonusers of CAM - at least regarding the evaluated predictors. Nevertheless, there may be differences between CAM users and non-users in terms of patients perceptio of disease, expectatio towards treatment or preferences for shared decision making. These factors would be interesting to assess in future surveys. In some of the prior studies patients were asked to state the perceived effects of CAM treatment [10;11]. In the survey of Hilsden 67% of present CAM users and 35% of prior CAM users resp. reported beneficial effects regarding their IBD symptoms [11]. In the Quattropani survey 61% of the patients reported an improvement while using CAM [10]. However, no further differentiation regarding specific CAM methods was reported in these studies. In our survey the perceived beneficial effects varied between 57% for probiotic therapy and 34% for treatment with classical naturopathy incl. herbals. Although explanatory power of this data is limited it can be regarded as an indicator for patients satisfaction with a specific CAM method. A strength of the study is that CAM was defined clearly within the questionnaire and that CAM methods most commonly used among German patients were predetermined in the questionnaire. Furthermore, the survey was based on patients participating at IBD workshops organized by a self-help association but open for public. In contrast, most of the previous studies only included patients visiting special IBD clinics [8;11;14]. We therefore surveyed a less pre-selected collective. However, it was not a non-random sample and therefore a bias can not be excluded, because our population may still not be in conformity with the general IBD population, as 46% of the surveyed patients were members of the self-help association DCCV. Those patients may have different strategies to manage their disease. For example, they might take more respoibility for their health-care and the management of their CAM in IBD patients 11

13 treatment. The study may therefore overestimate the use of CAM among IBD patients. A limit of our study is that the respoe rate only could be estimated retrospectively, since the questionnaires were not handed out personally to each patient. It may be possible that some patients did not recognize the questionnaires or that patients interested in CAM rather tended to complete the questionnaire than patients not interested in CAM leading to a possible selection bias. However, this argument may be invalidated by a comparison of our results with the study of Langhorst et al. who surveyed a randomly drawn sample of German IBD patients [12]. We found high corresponding results regarding CAM use (52% vs. 51%) and the high popularity of homeopathy (53% vs. 55%). The most common CAM therapy used by patients in our survey was homeopathy. This finding might be influenced by the fact that homeopathy was established by S. Hahnemann, a German physician. Since homeopathic treatment is not reimbursed by the statutory health iurance, homeopathic therapies often are self initiated by the patients, provided by Heilpraktiker or by homeopaths (physicia with the additional qualification homeopathy ) in private practice. Unfortunately, in our survey we did not ask which CAM therapy was administered by which type of practitioner or which CAM therapy was self initiated by the patient resp. Perceived effects of the homeopathic treatment were less positive compared to the other CAM methods. Interestingly, in a Medline search no clinical study assessing the efficacy of homeopathic preparatio in patients with IBD could be found. Our data shows a frequent use of probiotics. This may be the coequence of several recently published clinical studies with probiotic preparatio in the treatment of UC and CD [16-18]. According to the positive results of those studies the usage of probiotics for maintenance of remission is recommended in the updated guideline for CAM in IBD patients 12

14 Diagnosis and Therapy of Ulcerative Colitis by the German Society of Digestive and Metabolic Disease and the Competence Network of IBD [19]. Therefore, in Germany probiotic therapy can be prescribed for the treatment of IBD and will be paid for by the statutory health iurance. Despite implementation of probiotics in the national guideline, this therapy is originated from the field of CAM and it is therefore an excellent example for an evidence-based integration of CAM into conventional treatment. Acupuncture/TCM was also frequently used by our IBD patients. Coidering the popularity of acupuncture the high number of physicia with an additional training in acupuncture therapy in Germany is not surprising. Moreover, also many Heilpraktiker provide acupuncture. Nevertheless, at present there are only a few observational studies on the effect of acupuncture in UC [20;21] and one single randomised, controlled study in MC patients [22]. MC patients showed a decrease of disease activity as well as an improvement in quality of life after acupuncture treatment in this study. One third of our patients reported a therapeutic approach with Boswellia serrata extracts/incee. Preparatio from the gum resin of Boswellia serrata have been used as a traditional remedy in Ayurvedic medicine in India for the treatment of inflammatory diseases. In clinical trials promising results were observed in patients with rheumatoid arthritis, inflammatory bowel disease and bronchial asthma, but to date results from larger randomised controlled studies are missing [23-25]. The therapeutic approaches with Boswellia serrata may have been self initiated by the patients or recommended by Heilpratiker. 55% of the patients reported side effects on their conventional medication and 20% were completely dissatisfied with their current conventional treatment. According to previous studies this might be the main reason for IBD patients to enter CAM CAM in IBD patients 13

15 treatment [8]. Side effects of CAM therapy were described by 14% of our IBD patients. Unfortunately, the questionnaire provided no further information about type or severity of the perceived CAM side effects. Only 23% of the IBD patients in our survey felt sufficiently informed about CAM. Conclusion Physicia should address their patients straightforward regarding CAM and offer evidence-based information about specific CAM methods. On the basis of available scientific data they should aim at guiding patients through the CAM jungle. At the same time, further clinical studies assessing the most commonly used CAM therapies are urgently needed. Research in CAM offers the chance to discover new treatment optio in the management of IBD but may also protect patients from ineffective and expeive pseudo -therapies. Competing interests: The authors declare that they have no competing interests. Authors contributio: SJ, BB, TR, JS and SW conceived the study and draft the manuscript. SJ, BB and EH participated in designing the study. All authors read and approved the final version of the manuscript. Acknowledgements: The authors thank the DCCV e.v. for their assistance with the study. Special thanks to Cornelia Mahler for their assistance in preparing the manuscript. CAM in IBD patients 14

16 References (1) Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994; 309(6947): (2) Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M et al. Trends in alternative medicine use in the United States, : results of a follow-up national survey. JAMA 1998; 280(18): (3) Zollman C, Vickers A. What is complementary medicine? BMJ 1999; 319(7211): (4) Maskarinec G, Shumay DM, Kakai H, Gotay CC. Ethnic differences in complementary and alternative medicine use among cancer patients. J Altern Complement Med 2000; 6(6): (5) Marstedt G, Moebus S. Gesundheitsberichterstattung des Bundes: Inapruchnahme alternativer Methoden in der Medizin. Heft 9 ed. Berlin; Germany: Robert Koch Ititut, Statistisches Bundesamt, (6) Haltenhof H, Hesse B, Buhler KE. Evaluation and utilization of complementary medical procedures - a survey of 793 physicia in general practice and the clinic. Gesundheitswesen 1995; 57(4): (7) Hartel U, Volger E. [Use and acceptance of classical natural and alternative medicine in Germany--findings of a representative population-based survey]. Forsch Komplementarmed Klass Naturheilkd 2004; 11(6): (8) Heuschkel R, Afzal N, Wuerth A, Zurakowski D, Leichtner A, Kemper K et al. Complementary medicine use in children and young adults with inflammatory bowel disease. Am J Gastroenterol 2002; 97(2): (9) Moser G, Tillinger W, Sachs G, Maier-Dobersberger T, Wyatt J, Vogelsang H et al. Relatiohip between the use of unconventional therapies and diseaserelated concer: a study of patients with inflammatory bowel disease. J Psychosom Res 1996; 40(5): (10) Quattropani C, Ausfeld B, Straumann A, Heer P, Seibold F. Complementary alternative medicine in patients with inflammatory bowel disease: use and attitudes. Scand J Gastroenterol 2003; 38(3): (11) Hilsden RJ, Verhoef MJ, Best A, Pocobelli G. Complementary and alternative medicine use by Canadian patients with inflammatory bowel disease: results from a national survey. Am J Gastroenterol 2003; 98(7): (12) Langhorst J, Anthonisen IB, Steder-Neukamm U, Ludtke R, Spahn G, Michalsen A et al. Amount of systemic steroid medication is a strong predictor for the use of complementary and alternative medicine in patients with inflammatory bowel disease: results from a German national survey. Inflamm Bowel Dis 2005; 11(3): CAM in IBD patients 15

17 (13) Deutsche Morbus Crohn / Colitis ulcerosa Vereinigung (DCCV e.v.). (14) Rawsthorne P, Shanahan F, Cronin NC, Anton PA, Lofberg R, Bohman L et al. An international survey of the use and attitudes regarding alternative medicine by patients with inflammatory bowel disease. Am J Gastroenterol 1999; 94(5): (15) Witt C, Keil T, Selim D, Roll S, Vance W, Wegscheider K et al. Outcome and costs of homoeopathic and conventional treatment strategies: a comparative cohort study in patients with chronic disorders. Complement Ther Med 2005; 13(2): (16) Rembacken BJ, Snelling AM, Hawkey PM, Chalmers DM, Axon AT. Nonpathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis: a randomised trial. Lancet 1999; 354(9179): (17) Kruis W, Fric P, Pokrotnieks J, Lukas M, Fixa B, Kascak M et al. Maintaining remission of ulcerative colitis with the probiotic Escherichia coli Nissle 1917 is as effective as with standard mesalazine. Gut 2004; 53(11): (18) Kruis W, Schutz E, Fric P, Fixa B, Judmaier G, Stolte M. Double-blind comparison of an oral Escherichia coli preparation and mesalazine in maintaining remission of ulcerative colitis. Aliment Pharmacol Ther 1997; 11(5): (19) Hoffmann JC, Zeitz M, Bischoff SC, Brambs HJ, Bruch HP, Buhr HJ et al. Diagnosis and therapy of ulcerative colitis: results of an evidence based coeus conference by the German society of Digestive and Metabolic Diseases and the competence network on inflammatory bowel disease. Z Gastroenterol 2004; 42(9): (20) Chen Z. Treatment of ulcerative colitis with acupuncture. J Tradit Chin Med 1995; 15(3): (21) Zhang X. 23 cases of chronic nopecific ulcerative colitis treated by acupuncture and moxibustion. J Tradit Chin Med 1998; 18(3): (22) Joos S, Brinkhaus B, Maluche C, Maupai N, Kohnen R, Kraehmer N et al. Acupuncture and moxibustion in the treatment of active Crohn's disease: a randomized controlled study. Digestion 2004; 69(3): (23) Ammon HP. [Boswellic acids (components of frankincee) as the active principle in treatment of chronic inflammatory diseases]. Wien Med Wochechr 2002; 152(15-16): (24) Gupta I, Parihar A, Malhotra P, Singh GB, Ludtke R, Safayhi H et al. Effects of Boswellia serrata gum resin in patients with ulcerative colitis. Eur J Med Res 1997; 2(1): (25) Gerhardt H, Seifert F, Buvari P, Vogelsang H, Repges R. [Therapy of active Crohn disease with Boswellia serrata extract H 15]. Z Gastroenterol 2001; 39(1): CAM in IBD patients 16

18 Table 1: Sociodemographic and disease-related characteristics of the study population Characteristics Sex (%) Male Female Age (%) Diagnosis (%) Crohn s Disease Ulcerative Colitis Location (% of location) Erlangen Aachen Tuebingen All Patients (n=413) CAM user (n=215) CAM nonuser (n=198) P value # Duration of disease (median) Previous hospitalisation (%) Previous surgery (%) Current Medication (%) SASP or 5-ASA Corticosteroids Immunosuppressive Patient satisfaction with current therapy (%) satisfied neutral dissatisfied Side effects of conventional medication (%) Members of DCCV (%)* Academic education (%)* If not stated otherwise, all values are percentages of CAM users and CAM non-users resp. # p value for the comparison of CAM users and non-users *This item was missing for Erlangen patients. For some items the numbers may not add up to the total number because of missing respoes CAM in IBD patients 17

19 Table 1: Sociodemographic and disease-related characteristics of the study population If not stated otherwise, all values are percentages of CAM users and CAM non-users resp. # p value for the comparison of CAM users and non-users Note: For some items, the numbers may not add up to the total number because of missing respoes. *This item was missing for Erlangen patients. Table 2: Previous or present use of CAM Patients using CAM Classical naturopathy n (% of CAM users) 82 (38 %) Boswellia serrata n (% of CAM users) 78 (36 %) Probiotics n (% of CAM users) 44 (43 %)* Acupuncture/TCM n (% of CAM users) 70 (33 %) Homeopathy n (% of CAM users) 119 (55 %) * calculated for n=102 CAM users, because this item was missing in the Erlangen questionnaire. CAM in IBD patients 18

20 Table 3: Subjective rating of the efficacy of CAM treatment Satisfied with CAM treatment n (%) No change n (%) Uatisfied with CAM treatment n (%) Classical naturopathy (n=82) 28 (34%) 17 (21%) 30 (37%) Boswellia serrata extract (n=78) 34 (44%) 9 (12%) 21 (27%) Probiotics (n=44) 25 (57%) 6 (14%) 7 (16%) Acup./TCM (n=70) 34 (49%) 15 (21%) 14 (20%) Homeopathy (n=119) 47 (39%) 28 (24%) 42 (35%) CAM in IBD patients 19